Alz.org



Sample Letter Instructions (Sections marked in bold are mandatory)

Date: MM/DD/YYYY (within the past 12 months)

To: National Finance Center

Pre-Existing Condition Insurance Plan

P.O. Box 60017

New Orleans, LA 70160-0017

From: Name of Doctor, Physician Assistant, or Nurse Practitioner

Address: (Unless in Letterhead/Footer)

License #: License number of Doctor, Physician Assistant, or Nurse Practitioner

State of Licensure:

Subject: Patient’s Name, DOB

To Whom It May Concern,

For the purpose of qualifying for the Pre-Existing Condition Insurance Program (PCIP), please find this letter as confirmation that (Patient’s Name) has or had the following pre-existing condition(s) within the past 12 months:

If you require any clarification, please contact me via the following phone number:

XXX-XXX-XXXX

Sincerely,

Signature of Doctor, Physician Assistant, or Nurse Practitioner

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download